Axenfeld-Rieger syndrome (ARS) is a relatively rare developmental disorder characterized by maxillary hypoplasia, anterior segment defects of the eye (with glaucoma in ∼50%), and dental and umbilical abnormalities. The PITX2 homeodomain-containing transcription factor gene plays a major role in this condition, explaining approximately 40% of classic ARS.1–5 In addition, PITX2 mutations were shown to cause isolated ocular conditions,6–8 to be associated with additional brain anomalies,9,10 and possibly to contribute to other phenotypes such as omphalocele and VATER-like association.11 The function of Pitx2 is conserved in vertebrates. Total or conditional knockouts of Pitx2 result in severe developmental phenotypes in mice that include craniofacial, ocular, dental, brain, heart, lung, and other systemic defects consistent with the expression sites of Pitx2. With respect to Axenfeld-Rieger syndrome, Pitx2-deficient mice exhibit arrest of eye and tooth organogenesis, defective body wall closure and brain abnormalities.12–17 The defects observed in mice are associated with a complete loss of Pitx2 activity in the corresponding structures and, therefore, are noticeably more severe that what is reported in humans with heterozygous PITX2 mutations, whereas heterozygous mice are generally described as normal. This suggests a variable requirement of PITX2/Pitx2 for normal human/mouse embryogenesis, with human development more sensitive to correct PITX2 dosage. Human PITX2 mutations mainly result in a complete or partial loss of function, with mutations retaining some wild-type activity producing milder phenotypes.18–20 Some mutations identified in patients with Axenfeld-Rieger syndrome displayed very minor defects in DNA-binding and transactivation activities, again suggesting that normal human development is highly susceptible to alterations of PITX2 function.5 In addition, several human mutations associated with gain-of-function have been reported,21 consistent with the dramatic ocular and limb phenotypes seen in mice with Pitx2 overexpression during eye and forelimb development.22,23 Therefore, correct dosage of PITX2 is critical for normal development, which further underscores the importance of precise transcriptional regulation of its expression. Regulation of Pitx2 expression has been studied by several groups, but only a few cis-regulatory elements have been identified and examined in animal models. In mouse, Pitx2 appears to be a part of the Wnt/β-catenin/TCF/LEF and cAMP-CREB signaling pathways.24,25 Transcriptional activation of Pitx2 during eye development has been shown to be dependent on retinoic acid signaling26–28; the nature of this interaction, direct or indirect, has not yet been established. A few studies reported in vivo identification of Pitx2 enhancer elements, which facilitated upstream factor analysis. Asymmetric Pitx2 expression in the developing visceral organs was shown to require an intronic enhancer located in the proximity of the last exon,29,30 whereas a 7-kb fragment located 4.2 kb downstream of the last exon of Pitx2 was found to direct reporter expression in the oral ectoderm and Rathke's pouch.31 Finally, several regulatory elements associated with pitx2 expression in the stomodeum territory have been isolated in ascidians; the cis-sequences were either intronic or located within 2.5 kb of the 5′ or 3′ end of the gene.32 PITX2 is flanked by glutamyl aminopeptidase (aminopeptidase A) (ENPEP) located approximately 54 kb downstream and chromosome 4 open reading frame 32 (C4orf32) expressed sequence positioned approximately 1.5 Mb upstream of PITX2; thus, the 1.5-Mb sequence upstream of the gene is considered a gene desert. Gene deserts often contain conserved sequences involved in transcriptional regulation of nearby genes.33 The presence of PITX2 regulatory elements in this region were consistent with the previous reports of patients with Axenfeld-Rieger syndrome with translocation breakpoints that occurred within the distant upstream region and did not disrupt the coding region of PITX2.1,2,34,35 We describe identification of several novel regulatory sequences in the PITX2/pitx2 region, including several distant elements located within the gene desert upstream of PITX2. The activities of these elements appear to be consistent with PITX2/pitx2 expression, suggesting that they play a role in this gene's function. In addition, we report the identification of a de novo deletion located 106 to 108 kb upstream of PITX2 in a patient with Axenfeld-Rieger syndrome, thus providing additional support for the essential role of the identified regulatory elements in PITX2 function.